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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 465--6781 ' 7� r7 t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP 'PERMIT Permit No. 7 7 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) ; <br /> Application is Hereby made to the San Joaquin Local Health District for a permit to construct j <br /> and/or install the work herein described. This application is made in compliance with San Joaquin ; <br /> County Ordinance No. 1852 and the Ru d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA14M i CENSUS TRACT <br /> Owner's Name 7N4Phone <br /> Address Cit Mi <br /> Contractor's Name License one <br /> y <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR 0 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGETPIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ` Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT j_/ State Work Done <br /> IL- <br /> PUMP .REPAIR: State Work Don - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material. and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well. -construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ' > TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT/USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY / DATE ' 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br />